Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

911: you are correct, sir. This is 3rd degree block. The ventricular escape isn't completely regular in this snapshop.

anon: the thing that distinguishes this from Mobitz type II 2nd degree block and makes it 3rd degree block is the fact that there is no AV conduction anywhere. In other words, no P wave ever leads to a QRS.

A fine edition indeed. I think you're probably going to be a cross between 911Doc and A more "tactful" version of Etotheipi," but who knows maybe you're just shrodingers cat, DRX and the oldfart all mixed together. Well, whoever you are, it's been good reading your posts.

Got a great laugh out of the "internet is a bunch of tubes" comment. Glad to have you aboard. Our cardiologists get upset when we place or try to place temp transvenous pacers, because we're honing in on their business, plus, most people can be bridged with transcutaneous. I have one partner that just goes right in and puts a transvenous in everyone and gets in trouble.

brn: I passed your sentiments along to Mom. She appreciated it (as do I).

lynn: Loved the panty hose!

etotheipi: LOL. Thanks.

Fiz: EMS had the external pads on her, but they never turned it on since she was mentating pretty well and had an acceptable blood pressure. I thought that was reasonable. Ended up being one of my favorite medics that picked her up. He feared that I'd be pissed that he didn't pace her externally, but I thought he did well.

I'm not a huge fan of the external devices. In my experience, it seems like I have to turn the mA up so high to get "capture" that the patient doesn't tolerate them, or I have to drug the patient to near hypotension to tolerate the thing. It's always worth a try, but I find that it doesn't work well often.

I have a great story about my intern year and my first patient as a doctor that I'll share sometime.

fiz: yes, it's 3rd degree. If there were conduction from the atria, the QRS would be narrow. Since the QRS is wide, it tells you that it's either a ventricular ectopic beat, or a bundle branch block.

In 3rd degree block, it's not unusual to see a "pattern" since the atrial beats are regular and often the ventricular beats are regular as well. But they're not connected.

It's often confusing.

As a funny aside, the on call cardiologist read it as 3rd degree block, Mom's cardiologist read it as 3rd degree block, but the "official reading" (the one that we'll be billed for) from the internist on call to read the day's tracings was "Afib with Slow Ventricular Response"! There's no way!